Background
While Transfemoral Carotid Artery Stenting (TFCAS) is a valid minimally invasive option
for patients who also might be suitable for carotid endarterectomy (CEA) or transcarotid
artery revascularization (TCAR), alternative access sites such as transbrachial (TB)
or transradial (TR) are only utilized when anatomic factors preclude direct carotid
or transfemoral access. In this study, we aimed to evaluate the outcomes of TR/TB
access in comparison to TF for percutaneous carotid artery revascularization.
Methods
All patients undergoing non-TCAR carotid artery stenting (CAS) from January 2012 to
June 2021 in the Vascular Quality Initiative (VQI) Database were included. Patients
were divided into 2 groups based on the access site for CAS: TF or TR/TB. Primary
outcomes included stroke/death, technical failure and access site complications (hematoma,
stenosis, infection, pseudoaneurysm and AV fistula). Secondary outcomes included stroke,
TIA, MI, death, non–home discharge, extended length of postoperative stay (LOS) (>1 day),
and composite endpoints of stroke/MI and stroke/death/MI. Univariable and multivariable
logistic regression models were used to assess postoperative outcomes, and results
were adjusted for relevant potential confounders including age, gender, race, degree
of stenosis, symptomatic status, anesthesia, comorbidities, and preoperative medications.
Results
Out of the 23,965 patients, TR/TB approach was employed in 819 (3.4%) while TF was
used in 23,146 (96.6%). Baseline characteristics found men were more likely to undergo
revascularization using TR/TB approach (69.4% vs. 64.9%, P = 0.009). Patients undergoing TR/TB approach were also more likely to be symptomatic
(49.9% vs. 28.6%, P < 0.001). Guideline directed medications were more frequently used with TR/TB including
P2Y12 inhibitor (80.3% vs. 74.7%, P < 0.01), statin (83.8% vs. 80.6%), and aspirin (88.3% vs. 84.5%, P = 0.003) preoperatively. On univariate analysis, patients with TB/TR approach experienced
higher rates of adverse outcomes. After adjusting for potential confounders, TR/TB
patients had no significant increase in the risk of stroke/death [aOR 1.10 (0.69–1.76),
P = 0.675]; however, the use of TR/TB access was associated with a more than 2-fold
increase in risk for in-hospital MI [aOR 2.39 (1.32–4.30), P = 0.004] and 2-fold increase in risk of technical failure [aOR 2.21 (1.31–3.73) P = 0.003]. The use of TR/TB access was also associated with a 50% reduction in the
risk of access site complications [aOR 0.53 (0.32–0.85), P = 0.009].
Conclusions
This study confirms that although technically more challenging, TR or TB approach
serves as a reasonable alternative with lower access site complications for CAS particularly
in patients where anatomic factors preclude revascularization by TFCAS or TCAR. However,
TR/TB is associated with an increased risk of technical failure and myocardial infarction,
which requires further study.
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Article info
Publication history
Published online: February 06, 2023
Accepted:
January 19,
2023
Received:
November 29,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Funding sources: No funding was provided.
Presented at the Vascular Annual Meeting, June 15–18, 2022, Boston, MA.
Disclosures: EM: Medtronic, Abbott Vascular, Boston Scientific (Clinical Trials Research).
Author contributions: MAK, TSD, CJ, RJP, EM, and MBM contributed to the conceptual framework, methodology, design of the study, interpretation of results and critical revision. MAK performed the analysis and wrote the manuscript with input from TSD, CJ, and RJP. MBM and EM critically reviewed and edited the manuscript.
Identification
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